AN INTRODUCTION TO RETHINKING SOMATIZATION
Ian R. McWhinney, O.C., M.D.
Ronald M. Epstein, M.D.
Tom R. Freeman, M.D., CCFP
Reproduced with permission from the Fetzer Institute.
The article, Rethinking Somatization, was first published in the Annals of Internal Medicine in 1997. (http://www.acponline.org/journals/annals/)
It was our thought that the article bore directly on the ongoing discussion in ADVANCES on the concept of somatization and somatoform disorders. The editor of ADVANCES responded positively to the suggestion that he reprint the article Ė which he came to describe as a kind of anticipatory comment on the discussion Ė and that the article be open to responses from contributors to the discussion.
In this introductory note, we respond to a request from the editor, that we explain what we think our article adds. To us the answer is clear. We believe that it takes a position on the concept of somatization which has so far not entered the discussio n, namely that the concept, and the language in which it is expressed, should be abandoned. Why such a radical step? Because the concept and the language are so fundamentally flawed that the field, following Kuhnís analysis of why the search for scientifi c understanding at times takes dramatic shifts (Kuhn, 1967), can only be "[reconstructed] from new fundamentals, a reconstruction that changes some of the fields most elementary theoretical generalizations."
One of these generalizations is the mind/body dualism deeply embedded in modern medicine. The concept of somatization rests on the transduction of repressed emotion and psychological conflicts into bodily symptoms. As Wickramasekera put it in his artic le in ADVANCES (Wickramesekera, 1998), the somatoform patient keeps secrets from the mind, but not from the body. But for a person to disclose a secret to the body which is kept from the mind, we would have to postulate a disembodied self who can have an experience but choose to withhold it from either body or mind. This is surely intolerable. If there is a unitary person, this person must be a body/mind, from which separate body and mind are abstractions.
To treat these abstractions as concrete realities is to fall into what Whitehead (1926) called "the fallacy of misplaced concreteness". It is the unitary person who has experiences which are laid down in the body/mind where they may lie beneath the lev el of consciousness. As Guthrie (1998) observed in her commentary on Wickramasekeraís paper, somatization is normal: experience is embodied; the emotions are embodied. When embodied emotions become disabling, healing may require expression of suppressed e motion, so that the memory enters consciousness and integration is restored. The process may vary in difficulty from patients who are on the verge of making the step themselves, to those who require a trusting, committed relationship with a healer who has the self-knowledge to be aware of his or her own biases and who is willing to accompany them in a long course of self discovery (Epstein et al, 1999). Achieving the restoration of wholeness often involves expressing emotions in words, but not necessarily so. Emotions may be expressed in other ways (having a good cry). Integration may be achieved through bodily practices such as physiotherapy, meditation, breathing techniques and relaxation (Kabat-Zinn, 1990). Restoration of function after a sudden shock was familiar to pre-modern physicians. (Rather, 1965). We have seen the immediate disappearance of somatic symptoms in patients after such traumatic experiences as domestic fires.
The fact that body and mind are abstractions does not necessarily invalidate them as maps and guides to the territory of illness. When our map proves to be a good guide, we can have confidence in its abstractions, but when we become confused, frustrate d, and lose our way, it is time to consider that the map may be wrong,
In our medical education, we learn a language that is expressive of mind/body dualism, with terms like organic, psychosocial, and psychosomatic. Even the term biopsychosocial, as Engel himself acknowledged, is open to the interpretation that a patientí s illness can be compartmentalized in this way and that the physician can look after the biomedical part and the psychologist or social worker the psychosocial. Dualism runs like a fault line through medicine. Each side of the line has its own textbooks, clinical methods, and nosology. For physicians educated in this way, bodily symptoms without bodily signs, or chronic illness without organ pathology, are a source of confusion and frustration. The logical inference from the structure of medical knowledge is "If it isnít organic, it must be psychiatric": hence the term "functional", originally a descriptive term for the patientís disorder, becomes synonymous with "psychogenic". Our education makes it difficult for us to believe in the reality of an illnes s without organ pathology. A doctorís statement "I donít believe in chronic fatigue syndrome" (the map is wrong) may become "I donít believe you are really ill" (there is no such territory), and there are a hundred ways of saying to a patient "I donít bel ieve you".
Dualism can be replaced only by a unitary theory of the person, with mind and body viewed as two sides of the same coin or the inside and outside of the same vessel. Broom (1997 and 2000) provides a radical exposition of such a theory based on his exte nsive clinical experience. A unitary theory can deal with complexity. As several contributors to the discussion have observed, an illness such as chronic pain may require attention to numerous factors interacting in a non-linear relationships. A partial l ist of factors might include the circumstances surrounding the origin of the pain, previous history of pain, tissue damage (primary or secondary), emotions, thoughts and mood, coping strategies, maladaptive responses, family relationships and attitudes, f amily of origin issues, previous and present doctor-patient relationships, education, social and economic status, and medical-legal issues.
The list of disorders cited by Wickramasekera in his article (1998) as examples of emotionally derived somatization cover a wide range of disorders, including: a continuously distributed variable that is arbitrarily designated at a certain point as abn ormal (hypertension); a disabling illness with the hallmarks of an immunological response to infection (chronic fatigue syndrome); and an intermittent condition with a well defined neurological basis (vascular headache). To expand the definition of somati zation to include these illnesses is a category error which reduces the value of theories based on alexithymia and the repression of emotion. It is surely more logical to acknowledge that the emotions are involved in all serious illness, though in many di fferent ways, especially in their capacity as causal agents.
The absence of organ pathology, even in patients with extreme prostration, seems a contradiction to modern physicians because they focus their attention on the organs rather than on higher level functions of the neuro-endocrine-immunological axis and o n the affective influences which operate at this level. There is empirical evidence for malfunction at this level in disorders such as chronic fatigue, (Demitrack et al, 1991; Bearn & Wessely, 1994; MacHale et al, 1998; Sharpe et al, 1997). This level of malfunction may well account for the great diversity of symptoms in patients with chronic fatigue and the unpredictability with which they come and go, a feature that is often mistakenly interpreted as evidence of neuroticism.
When we cease to speak of somatoform disorders, what do we put in their place? Our current nosology has great difficulty in dealing with illnesses with no organ pathology, or with organ pathology that does not fully explain the illness. Our clinical me thod is still based on the notion of disease as having location in the body. We should consider reviving the older idea of diagnosing a patient rather than a disease (Crookshank, 1926). With the so called somatoform illnesses we are indeed dealing with il lnesses of the whole person.
Wickramasekera proposes that primary care physicians should deal with the organic components of somatic symptoms, working with psychophysiologists to educate "chronic somatoform patients." Wessely et al are critical of the tendency for patients with fu nctional disorders to be referred to system specialists such as rheumatologists and gastroenterologists. They argue for the return of the general physician aided by liaison with psychiatrists and psychologists. Our concern is that these proposals would te nd to perpetuate the existing dualism. The general internist of the recent past was usually entrenched on one side of the fault line, as was the clinical method taught in medical schools. Integration has to start in the hearts and minds of clinicians.
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